For five years, it was one of the most widely praised health centres in southern Africa: a Canadian-funded AIDS clinic in a remote corner of Lesotho that brought care to 11,000 people, saving lives and raising standards to North American levels.

Now, after a dispute with the Lesotho government, the Canadian donors are warning of a nightmare scenario. Patients could die, they say, and the clinic could spark a public-health crisis by spreading drug-resistant HIV strains across the border to South Africa.

Health professionals at the clinic are already beginning to leave, and key programs are disintegrating. “This is a life-and-death urgent matter for the people of the region,” said Philip Berger, a Toronto doctor who specializes in AIDS treatment and has worked at the Lesotho clinic as recently as December.

The Canadian supporters, who invested $4-million in the clinic and recruited nearly 50 Canadians to work in it, issued a dramatic warning to the government this week. In a letter to Lesotho’s health minister and Prime Minister, they warned of the “far-reaching impact” that could be triggered if a drug-resistant virus is “transmitted throughout the country and potentially across borders.”

Lesotho already has one of the highest HIV infection rates in the world, with 24 per cent of its people infected by the virus. Many migrate to South Africa for jobs, increasing the danger of cross-border transmission if drug-resistant HIV strains are produced.

The clinic, called Tsepong (Place of Hope), will be taken over by the Lesotho Health Ministry on March 31 after five years of Canadian control. But the ministry has refused to promise that the 15 Canadian-funded nurses and other health staff will be kept on the payroll, despite pleas from the funders, led by OHAfrica, a group affiliated with the Ontario Hospital Association, which helped set up the clinic in late 2004.

For the 3,500 patients who are currently getting AIDS medicine at the clinic, even a single day of disruption in their treatment could create a drug-resistant virus, Dr. Berger said. If the staff continues to leave, it will be impossible to continue providing medicine to the patients, he said. “They won’t get drugs if the system is collapsing. People will get sick and die. Patients are saying, ‘People will die.’”

In her letter to the Lesotho government, OHAfrica board chairwoman Hilary Short noted that the clinic has been “performing at a level as advanced as the best primary HIV/AIDS clinics in Canada.” But the government has given “no indication of their intentions regarding the continued staffing of the clinic,” she wrote. “In the absence of these staff, patients are at serious risk of untreated conditions and death.”

A report in the Lesotho Times, a weekly newspaper, said the patients at the clinic are worried about the departure of the Canadians. “Patients are beginning to see the huge gap they have left filled immediately,” the report said. It quoted one volunteer who said the staff are overburdened.

. “With the Canadians leaving one by one, work has become too much and at times they are overwhelmed,” the volunteer said.

The clinic’s takeover by the Lesotho government was originally presented as a normal transition from foreign to national control. In January, the Canadians issued a brief announcement of the takeover, saying they had always wanted the clinic to be “locally sustainable.”

But this week, after the strongly worded letter from OHAfrica to the Lesotho government, the dispute became more obvious. In response to questions from The Globe and Mail yesterday, Lesotho Health Minister Mphu Ramatlapeng criticized how the Canadians had run the clinic. “They experienced a very high turnover of staff and they failed to meet certain targets,” she said in an e-mail to The Globe. “They failed to integrate the clinic services with the services of the main hospital. They also failed to assist us with decentralized services to the clinics.”

She said she will “not respond” to the public-health concerns raised by OHAfrica in its letter to the minister this week. “Only scientific evidence can provide answers,” she said.

“It is important for the OHAfrica team to understand that they have done well, but it is now time to leave and let the government of Lesotho manage the clinic in the same way that similar clinics are managed country-wide.”

Ms. Short said the government had never mentioned these concerns to the Canadians. “I’m puzzled by it,” she said in an interview. “If they had shared these concerns with us, we would certainly have dealt with them. We had tried to be very collaborative with the hospital, and to take our services to the field.”

The criticism of the high turnover was “fair comment,” she said, but OHAfrica had tried to persuade staff to stay longer at the clinic. “It’s very hard to get nurses and doctors and pharmacists to stay for a long time.”

Ms. Short said she is bewildered by Lesotho’s refusal to promise to retain the existing staff. Other humanitarian agencies have also left Lesotho in recent years because the government “wants to do things on their own,” she said.

She said she is still hoping that the government will change its mind. This week OHAfrica met with Lesotho’s high commissioner in Canada to try to solve the issue, but there was no agreement.

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